a) Beneficiary/ Recipient: Name and Surname or Company´s registered name.

b) Tax domicile:

c) Income Origin (Article of the Agreement).

d) Affidavit of the beneficiary/recipient of the income, or in case of a Company, its legal representative: The undersigned states that he/she/the Company is resident in ...................... and that he/she/ the Company does not own permanent establishment or fixed base in Argentine Republic, and likewise that he/she/the Company meets all compulsory requirements in order to apply to this agreement.

Date

Signature of the beneficiary/recipient of the income, or in case of a Company, its legal representative.

e) Certification of the competent authority of ......................................

I do hereby certify that the beneficiary/recipient of the aforementioned income is a resident in ......................... as regards of the agreement to avoid double taxation between Argentina Republic and ........................ Likewise, as regards the above subsection, this competent authority ratifies/ denies/does not know the statement of the beneficiary/recipient as far as he/she/the Company does not own a permanent establishment or fixed base in the Argentine Republic.